CHILDCARE ASSISTANCE PROGRAM - Ho-Chunk Nation...Aug 10, 2019 · The Childcare Assistance Program is designed to assist Ho-Chunk families using CCDF grant funds to subsidize

HO-CHUNK NATION COMMUNITY SUPPORTIVE SERVICES DIVISION OF HO-CHUNK NATION SOCIAL SERVICES

CHILDCARE ASSISTANCE

PROGRAM

POLICY MANUAL

8 0 8 R E D I R O N R O A D * B L A C K R I V E R F A L L S , W I 5 4 6 1 5

OCTOBER 1, 2018 – SEPTEMBER 30, 2019

Updated: 10/22/18

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CHILDCARE ASSISTANCE PROGRAM 2018

Table of Contents

ADMINISTRATION .................................................................................................................................................. 3

OTHER WISCONSIN COUNTIES/AREA 4-5.................................................................................................................. 3

SERVICES OFFERED .................................................................................................................................................. 3

SPECIAL NEEDS ........................................................................................................................................................ 4

PROTECTIVE SERVICES/AT-RISK ............................................................................................................................... 4

ELIGIBILITY REQUIREMENTS FOR PARENT(S)/GUARDIAN(S) ...................................................................................... 5

ELIGIBILITY REQUIREMENTS FOR CHILDREN ............................................................................................................. 5

REPORTING CHANGES ............................................................................................................................................. 5

CO-PAYMENT .......................................................................................................................................................... 6

END OF EMPLOYMENT/END OF EDUCATIONAL PROGRAM ....................................................................................... 6

MATERNITY LEAVE POLICY....................................................................................................................................... 6

REQUIRED DOCUMENTS FOR CONSIDERATION OF ASSISTANCE ................................................................................ 7

FEES COVERED UNDER THE PROGRAM ..................................................................................................................... 8

FEES NOT COVERED UNDER THE PROGRAM ............................................................................................................. 8

DECISION OF ELIGIBILITY ......................................................................................................................................... 8

APPROVED APPLICATION FOR ASSISTANCE .............................................................................................................. 9

ELIGIBILITY AND REVIEW PROCESS ........................................................................................................................... 9

WAITING LIST ELIGIBILITY ...................................................................................................................................... 10

APPEAL PROCESS................................................................................................................................................... 10

OFFICE LOCATION ................................................................................................................................................. 10

Appendix

CHILDCARE ASSISTANCE APPLICATION .............................................................................................................. 12-14

VOUCHER PAYMENT POLICY AGREEMENT.............................................................................................................. 15

DISCHARGE POLICY AGREEMENT ........................................................................................................................... 16

RELEASE OF INFORMATION AGREEMENT ............................................................................................................... 17

SLIDING FEE SCALE (Determines Income Eligibility and Co-Pay Amount) ................................................................... 18

COMPLAINT REPORTING FORM ............................................................................................................................. 19

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ADMINISTRATION

This Policy Manual follows the guidelines as outlined in the Child Care Development Fund (CCDF) block grant,

which is received through the Administration for Children & Families in Washington DC. The Grant funding

year begins October 1st through September 30th of each year. Since grant and supplemental Net Profit

Distribution (NPD) funds are limited - funds are obligated to families on a first come, first serve basis with

the exception of Protective Services and At-Risk children (priority services given based on funding). If all

funding sources have been obligated, applicants will be put on a waiting list until an opening for assistance

occurs.

It is required as part of the application process that the parent(s) must also go through their county/state of

residence for child care assistance. Applications are still accepted regardless of approval or denial of state

assistance as long as all eligibility requirements were carried out. The Child Care Assistance Program (CCAP)

requires parents to utilize all their sources of funding. Policies can change without notice if deemed necessary

for the integrity of the program.

It is required that the parent/guardian(s) are current on all financial obligations with their child care provider

before acceptance into CCAP.

The Childcare Assistance Program is designed to assist Ho-Chunk families using CCDF grant funds to subsidize

child care costs for their tribally enrolled children residing in the following Wisconsin counties:

Adams Eau Claire Sauk

Clark Jackson Shawano

Columbia Juneau Monroe

Crawford La Crosse Vernon

Dane Marathon Wood

OTHER WISCONSIN COUNTIES/AREA 4 - 5

Net Profit Distribution (NPD) funding is on a first come first serve basis until all funds are obligated. Since all

funding sources are limited and amounts vary from year to year; it is required that the parent(s) must first go

through their county/state of residence for child care assistance in addition to the tribal application process.

SERVICES OFFERED

The Child Care Assistance Program (CCAP) provides financial assistance for Parent(s)/Guardian(s) for child care

expenses. The program operates on a voucher system with payment going directly to the child care provider.

Child Care Center Requirements – Only State licensed, State Certified and Faith Based centers that

follow the Wisconsin Model of Early Learning Standards. Boys & Girls Clubs, YMCA’s and YWCA’s are acceptable if they comply with state health and safety standards.

Parent(s)/Guardian(s) Requirements – Parent(s)/Guardian(s) Must be attending an education program

and/or working full or part-time at least 20 hours per week.

Income Requirements – Parent(s) gross income cannot exceed the income guidelines as established

through CCAP. Per Capita IS NOT included as income. (See Fee Scale located in Appendix)

Child Requirements - Child must be an enrolled Ho-Chunk tribal member or eligible and in the process

of enrollment.

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SPECIAL NEEDS

Priority services are given to children with Special Needs as it relates to program funding availability. All

program requirements apply including family income guidelines and copayments.

Specific Needs Request:

If the child care center has determined that a special need is required for a child to improve the quality of life

in the child care center, where the child spends most of their time, a request can be made to CCAP. The

funding request must provide the following information:

1. Documentation from a qualified professional; a physician, psychologist, special educator, or other

qualified health care professional that has diagnosed the child with a special need.

2. A recommendation by the child care center director including child’s name, the nature of the request and how this request would benefit the child’s daily activities in the child care center.

3. A cost estimate from at least 3 vendors.

PROTECTIVE SERVICES/AT-RISK

Priority services are given to families with children who are considered in Protective Services and At-Risk based

on funding availability. All program requirements apply including family income guidelines and copayments.

Copayments will be waived for Placement and Temporary Guardianship only. Appropriate

documentation/verification is required. Protective Services include:

1. Indian Child Welfare; Wards of the Ho-Chunk Nation (Placement) or families with Temporary Guardianship.

2. Referrals through a tribal or county Social Services agency.

3. Homeless circumstances or other harmful or crisis situations; which also includes Respite Care.

4. Referrals from other tribal or non-tribal Human Services professionals for children at risk of a health or social

condition. (I.e. parents completing a substance abuse program, parents working to assimilate into society after

incarceration by obtaining employment/education, etc.)

5. At-Risk also includes families at or below the poverty level for income guidelines established through the

program. Transition from Temporary Placement/Guardianship to Permanent Guardianship: Once a family becomes a child’s Permanent Guardian, the biological parent’s rights of that child are terminated and the Guardian’s assume the legal parental rights of the child until age 18. At this point, all program guidelines apply including

a copayment if still eligible for child care assistance.

Legal court documents are required with application materials. Once the family is eligible for services, legal

court documents are required within 5 business days of any change in Placement/Guardianship for re-

determination of eligibility of services.

a. Once notice has been given to the CCAP, a 30-day grace period is given for families to maintain child

care assistance and submit additional supporting documentation to determine the new eligibility

status for assistance.

b. All program requirements will then apply to family awarded Permanent Guardianship as family is

considered the legal parent of child until age 18.

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ELIGIBILITY REQUIREMENTS FOR PARENT(S)/GUARDIAN(S)

Parent(s)/Guardian(s) must be employed or in an educational program as defined:

Definition of Employed:

Permanent Full-Time/Part-Time Employment

Job training program

Contracted Limited Term Employee (LTE)

477 Program

W2 Program

Must lead to employment in local labor market.

Maximum subsidized care cannot exceed 50 hours per week without prior approval from CCAP Manager.

Parent(s)/Guardian(s) must be employed a minimum of 20 hours per week required.

Definition of Educational Program:

Enrollment in an accredited college of at least 6 credits; which can include online courses.

Enrollment in classes to obtain HS Diploma/HSED/GED.

Vocational Rehabilitation/Probation Terms: Until the program ends. Must notify Program immediately.

Documentation of class schedule and/or other supporting documents is required.

ELIGIBILITY REQUIREMENTS FOR CHILDREN

Child must be an enrolled Ho-Chunk tribal member or in the process of enrollment. There is a one year

grace period for enrollment. If the child still hasn’t obtained enrollment within one year of being on the program, the child will no longer be eligible for CCAP services.

Child must be a resident of the custodial parent(s)/guardian’s home at least 51% of the time. This includes placement/foster care children.

If assistance is requested by both parents who have shared physical custody (50/50); a separate

application is required by each family as they are considered separate households.

Child must be under the age of 13 unless they are considered ‘Special Needs’. Documentation is required to determine eligibility.

REPORTING CHANGES

Any changes in (but not limited to) income, person’s living in the home, a change in job/education status or child care needs must be reported within 5 business days.

Summer Absences

CCAP does not hold child care spots at child care centers during the summer months when school is not in

session. The only exceptions for absences from the child care center that are over a week long is cultural

events, a documented illness, or an extenuating circumstance that is approved by CCAP.

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CO-PAYMENT

The Parent(s) are responsible for a small portion of their weekly child care charges called a “Co-Payment” amount.

The Co-Payment amount is determined by the Fee Scale as set forth by the program guidelines. The

Fee Scale is based on family size, income and number of children needing child care assistance.

Co-Payment amounts are a set fee amount the Parent(s) pay weekly to the child care center as their

portion/responsibility of the child care charges. If the Parent(s) fails to pay their weekly co-payment

amount to the child care center; they are out of compliance with program guidelines and can be

dropped from program assistance.

The Co-Payment amount stays the same every week and does not change nor is it pro-rated if the child

is not in attendance for the full week.

END OF EMPLOYMENT/END OF EDUCATIONAL PROGRAM

If the Parent(s)/Guardian(s) employment/education ends, notification is to be given to the CCAP within (5) five

business days. Child care assistance can be utilized for up to a consecutive (3) three months for job

search/absence from school (i.e. summer break). The Job search/school break time frame is limited to one

occurrence within a 12 month period, at which time either employment must be established or payments will

not be authorized. The Parent(s)/Guardian(s) co-payment amount (parent responsibility) will be re-adjusted

to accommodate the change in family income for those three months.

MATERNITY LEAVE POLICY

Maternity Leave can be given for up to 12 weeks for Parent(s)/Guardian(s) that are on the program that are

taking time off of work to be with their new child. This allows for two things: (1) The parent’s children that are already in child care can be home with the parent(s) and new sibling if they so choose (2) The children

already in child care have their spot held for them until the parent returns to work.

During this time period, the maternity leave policy allows for payment of the provider’s usual charges (or some

portion thereof, if a lower charge for holding the slot can be negotiated) during the 12-week period, whether

or not the child attends. Co-Payments are waived while on Maternity Leave status.

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REQUIRED DOCUMENTS FOR CONSIDERATION OF ASSISTANCE

Applications for Child Care Assistance are accepted throughout the year. The following documents are

required to be considered for assistance and to determine eligibility:

1. Childcare Assistance Application: Application located in Appendix section of Manual

Family Size Excludes:

a. The non-custodial parent (if mother and father do not live in same residence)

b. The child’s other non-parental relatives who are not acting in loco parentis over age 18

c. Parent(s) children living in the home over 18

d. Any persons who may be staying in the applicant’s home under age 18 that the Parent/Guardian(s) does not include as providing support

2. Decision Letter For State Child Care Assistance: Approval or Denial Letter from State in which you

reside. Needs to indicate that parent(s)/guardian(s) have followed through with all eligibility

requirements for child care assistance and the decision of that application. Required at initial application

and yearly.

3. Child’s certificate of tribal enrollment (copy): Child must be an enrolled Ho-Chunk tribal member or

eligible and in the process of enrollment.

For children who are eligible for enrollment with the Ho-Chunk Nation and are in the process of

enrollment:

a. Verification is conducted to ensure the child is eligible for enrollment. For newborns,

documentation of parental blood quantum will be required to determine enrollment eligibility.

b. Parent(s) are afforded one (1) year to complete the enrollment process for their children to

maintain child care assistance.

4. Voucher Payment Policy Agreement: Agreement located in Appendix section of Policy Manual

5. Discharge Policy Agreement: Agreement located in Appendix section of Policy Manual

6. Release of Information Form: Form located in Appendix section of Policy Manual

7. Proof of Income: The program defines “Total Family Income” to include only the parent(s) income

where child resides or lives the majority (at least 51%) of the time.

a. Working Wages - Provide the last three paystubs from employer. If income is based on tips or

hours of employment vary by week; an average of the last three paystubs will be used to calculate

an average of income.

b. Disability Income –Documentation showing monthly Disability Income received

c. Social Security Income (SSI) – Documentation showing monthly SSI Income received

d. Per Capita payments is NOT included as income.

e. Child Support IS included in income

8. Proof of Residence: Rent/purchase/lease agreement. CCAP will accept other documentation of proof of

residence in lieu of rental/purchase/lease agreement if none is available.

9. Class Schedule: Shows number of credits taken in a given semester. (Minimum 6 credits)

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FEES COVERED UNDER PROGRAM

Yearly Enrollment/Registration Fees for Child Care Center - Child Care center’s yearly enrollment fees are

only allowable for payment once per year/per center/per child. If parent(s)/guardian(s) decides to switch

child care centers within a given year, the parent will be responsible for the new enrollment fee at the new

child care center.

Holidays – Holidays designated by the center the child attends and/or the Ho-Chunk Nation (if tribal

employee) are paid for by the program.

FEES NOT COVERED UNDER PROGRAM

Copayments - are the sole responsibility of the parent(s). A family’s co-payment is based on monthly

income, family size and number of children needing care.

Absent, sick, snow days, and any other days normally scheduled for a child’s attendance at a child care center.

a. These days may be waived if the parent/guardian provides the program written or verbal notice

within 24 hours of the absence.

b. These days may be waived if the child care center does not charge the Parent(s)/Guardian(s)

for the absent day.

c. We realize that extenuating circumstances do occur and approval of absent days is on a case-

by-case basis. If a child is absent three or more days from daycare due to illness, a doctor’s note may be required.

All other additional child care fees – Which includes, but not limited to: Holding fees, late fees, pick-

up/drop off fees, and copayments that are in arrears. If a child is consistently absent from child care and

there is a pattern of absences that have developed; the Child Care Assistance Program Manager reserves

the right to require supporting documentation on the nature of the absences.

DECISION OF ELIGIBILITY

The Child Care Assistance Program Manager is delegated the authority for reviewing the application as to the

accuracy and completeness of submitted application materials. Families who have received prior assistance

need to have met any past requirements that were not met while previously on the program such as but not

limited to enrollment status and outstanding child care fees. In addition, families need to have left in good

standing with the program to be considered for future assistance. Once it is determined that the applicant is

eligible; a final review is conducted by the Community Supportive Services Division Coordinator and/or

Director. If one person is absent to determine eligibility, the Executive Director of Social Services is included

in the decision making process.

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APPROVED APPLICATION FOR ASSISTANCE

When the family is determined eligible for services; the Child Care Assistance Program Manager will notify

the applicant(s) in writing via mail or electronically (email). The notification will include the following:

Acknowledgement of Program acceptance: To include a start and end dates of service and the co-

payment amount the family is responsible for.

Co-Payment Agreement: Agreement indicates the amount the parent(s)/guardian is responsible for

weekly (to the child care center); and also includes when services will begin and end.

a. Services begin when application is approved, NOT when application was submitted.

b. Parent(s)/Guardian(s) and Child Care Provider signature is required on this agreement.

Eligibility Worksheet and Sliding Fee Scale: Establishes how the Parent(s)/Guardian(s) co-payment

amount was determined.

Program Compliance Form (Previously known as ‘Checklist Form’): This form is validation that all

documents have been submitted by Parent/Guardian to be eligible for the program. It is also

justification to Ho-Chunk Nation’s Treasury Department for payments to be made to the child care

center for remaining balance as indicated on payment voucher. Signature is required by Program

Manager and Parent/Guardian acknowledging program compliance.

ELIGIBILITY AND REVIEW PROCESS

Families on the CCAP are required to go through the review process once per year to update required

information in order to maintain assistance. The yearly review process ensures program compliance

of program/grant guidelines.

Notices are sent to Parent(s)/Guardian(s) no less than two weeks prior to yearly review date.

Parent(s)/guardian(s) will be requested to submit updated documents as requested by Program

Manager at each review.

Adjustments to the yearly review can occur at any time if the family’s circumstances have changed and

modifications need to be made to the family’s household, income, or number of children needed

assistance. Parent(s)/Guardians are required to notify CCAP within five business days of any changes in

household information. Documentation of those changes will be required to determine the new eligibility

status.

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WAITING LIST ELIGIBILITY

Due to limited funds, a waiting list may form for assistance. Families that have submitted an application

and are waiting for assistance are prioritized in the following order:

1. Placement or Temporary Custody

2. Ho-Chunk Enrolled Children. Enrollment certificate included with application

3. Protective Services/At Risk

4. Children who are pending enrollment with proof of eligibility for enrollment.

A family that has received prior assistance with CCAP must have left the program in good standing. If there

are any program requirements from past assistance that were not abided by, it is the family’s responsibility to correct them before they can become eligible for assistance again with the program.

APPEAL PROCESS

Department of Social Services utilizes a ‘Complaint Reporting Form’ for appealing a decision you do not

agree with. The Complaint Reporting Form must be submitted within 10 (ten) business days of date on

denial notification. The Complaint Reporting Form is to be submitted to:

Executive Director of Social Services

HCN Dept. of Social Services; P.O. Box 40

Black River Falls, WI 54615

The complaint should state facts and should include:

1. Your identifying information – Name, address, phone and email address (if applicable).

2. The program you have a complaint with (check appropriate box on form).

3. Date of Complaint/Location of Complaint/Time/Person Involved

4. Description of Complaint - why you believe the decision is wrong. Specific information based on facts

and what the relief sought is.

All appeals will be addressed in a timely manner and will be followed up with a written response.

OFFICE LOCATION

808 Red Iron Road


P 715-284-2622

F 715-284-9486

Office hours: Monday – Friday: 8:00 am – 4:30 pm

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APPENDIX

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DOCUMENTS TO SUBMIT WITH APPLICATION INCLUDE:

Decision Letter for State Child Care Assistance

Copy of child’s certificate of Ho-Chunk Nation tribal enrollment

Voucher Payment Procedure Form

Discharge Policy Form

Release of Information Form

Proof of Income or Educational Training

Proof of Residence

Class Schedule – If applicable

**See Policy Handbook on Page 7 for descriptions of above documents needed**

-------------------------------------------------------------------------------------------------------------------------------------------------

SECTION I: Applicant(s)

Parent/Guardian Name(s)-Living in Home Date of Birth Tribal ID# (last 5 digits)

_____________________________ _______________ __________________

Parent/Guardian Name(s)/Spouse/Cohabitant Date of Birth Tribal ID# (last 5 digits)

_____________________________ _______________ __________________

Physical Address where you reside: Home Phone:

________________________________________________ __________________

________________________________________________

________________________________________________ Cell Phone:

__________________

Mailing Address: (if different)

________________________________________________

________________________________________________

________________________________________________

Email: **Most Communications are done electronically**

________________________________________________

Any Parent(s) Absent from the home? Please List: Absent Parent Physical Address:

________________________________________________ __________________________________

________________________________________________ __________________________________

Revised 07/2017

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_______________________________________________ _ __________________________________

Parent’s Place of Employment and Job Site/School/

Training Organization Work Phone

________________________________________________ __________________

________________________________________________

________________________________________________

How many hours per week are you employed and/or going to school? _____________hours

Parent/Spouse/Cohabitant Place of Employment and

Job Site/School/Training Organization Work Phone

________________________________________________ __________________

________________________________________________

________________________________________________

How many hours per week are you employed and/or going to school? _____________hours

SECTION II: List all children and others who reside in the home (Child must be under 13 years of age

unless disabled/verified Special Needs by a Physician to receive child care assistance.)

Date Child Care

Child’s Full Name Of Birth Needed? (Y/N) Age Sex Tribal #

1. _____________________ __________ ___________ Yes No ____ ______ ________

2. _____________________ __________ ___________ Yes No ____ ______ ________

3. _____________________ __________ ___________ Yes No ____ ______ ________

4. _____________________ __________ ___________ Yes No ____ ______ ________

5. _____________________ __________ ___________ Yes No ____ ______ ________

6. _____________________ __________ ___________ Yes No ____ ______ ________

7. _____________________ __________ ___________ Yes No ____ ______ ________

8. _____________________ __________ ___________ Yes No ____ ______ ________

9. _____________________ __________ ___________ Yes No ____ ______ ________

10. _____________________ ____ ___________ Yes No ____ ______ ________

Family Size Excludes:

The non-custodial parent (if mother and father do not live in same residence)

The child’s other non-parental relatives who are not acting in loco parentis over age 18

Parent(s) children living in the home over 18

Any persons who may be staying in the applicant’s home under age 18 that the Parent/Guardian(s) does not include as providing support

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SECTION III: Provider/Child Care Center your child(ren) currently attend or are considering:

Center/Provider Name Phone _____________________ __________ __________________________ Address Contact Person/People ________________________________________________ __________________________ ________________________________________________ __________________________ 2nd Center/Provider Name (If Applicable) Phone _____________________ __________ __________________________ Address Contact Person/People ________________________________________________ __________________________ ________________________________________________ __________________________

SECTION IV: RIGHTS AND ACKNOWLEDGEMENTS

1. I understand that all necessary documentation must be completed and turned in before the approval process can

begin. The child care provider must be a state certified/ state licensed/faith based following WI Early Learning Model

Standard or the state of residence equivalent. Initial______

2. I understand that I must apply for child care subsidy and receive a child care assistance determination letter from the

state in which I reside before my eligibility for CCAP can be determined. Initial______

3. CCAP is not liable for claims, demands, obligations, losses, costs, damages, fines, or any other type of liability, arising

out of or resulting from any act, omission, willful misconduct or gross negligence of the child care provider that is

chosen by the parent/guardian. Initial______

4. I understand policies can change without notice and I am subject to an annual review, random reviews and any absent

days not reported to the program in a timely manner as set forth by this policy.

Initial______

5. AFFIDAVIT: I swear or affirm that all the information provided above is true and understand that providing

false information, deliberate misinformation or intentional omission of information that results in obtaining

benefits may result in being barred from the program. Initial______

THE CHILD CARE ASSISTANCE PROGRAM IS SUBJECT TO CHANGE WITHOUT ADVANCE NOTICE.

I UNDERSTAND THAT I AM RESPONSIBLE FOR ANY CHILD CARE COSTS NOT PAID BY THE TRIBAL CCAP PROGRAM;

INCLUDING BENEFITS WHICH MAY HAVE BEEN AUTHORIZED, BUT FOR WHICH I NO LONGER QUALIFY BASED ON A

CHANGE IN CIRCUMSTANCES.

I HAVE READ AND UNDERSTAND ALL SECTIONS OF THIS FORM

APPLICANT_____________________________________________________________Date:____________

APPLICANT_____________________________________________________________Date:____________

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VOUCHER PAYMENT POLICY The submission of the Payment Voucher on a timely basis is the exclusive responsibility of both the parent and

the provider. CCAP is not responsible for; vouchers past two-weeks of last day of services, in arrears, and any

late fees. Absent days are subject to approval as per policy guidelines. All concerns must be in WRITING within

24 hours of any incident in question not covered by the Program

1. Provider -

a. Payment Vouchers are to be submitted on a weekly or bi-weekly basis. CCAP cannot assure payment

the same week.

i. Dates and hours of child care service are to be noted on voucher in either a one or two-week

period.

ii. Indicate county of child care center in space provided on voucher.

iii. Include full name and age of child.

iv. Enter the actual daily hours for each child. If a sign-in sheet is used CCAP may request a copy

of that form.

v. Circle the type of Child Care: State Certified, State Licensed, In-home (Special Needs Only).

vi. Complete Provider section. Payment Voucher must be signed and dated in the presence of

parent.

b. Taxes are the sole responsibility of the Child Care Provider

c. Child Care Provider provides yearly amounts paid by Parent(s)/Guardian for tax purposes.

2. Parent -

a. Review dates and charges for accuracy on voucher.

b. Sign and date voucher to acknowledge all is true to your knowledge (so provider can submit for

payment).

I have read and fully understand the process of submitting the Voucher Payment forms. My signature on this

form, states I am in agreement to follow these guidelines.

_______________________________________ ______________________

Parent Signature Date

_______________________________________ ______________________

CCAP Signature - verifying that Voucher Procedures Date

were discussed with Child Care Provider.

Page 16 of 19


DISCHARGE POLICY CHILD CARE ASSISTANCE PROGRAM (CCAP) RESERVES THE RIGHT TO INITIATE

IMMEDIATE/TEMPORARY/PERMANENT TERMINATIONS WHEN NECESSARY DUE TO ANY VIOLATION OF POLICY.

VIOLATIONS

1. Parent(s)/Guardian(s) failure to pay overdue absent fees or co-payments to your provider.

2. Parent(s)/Guardian(s)/Providers consistent inability to comply with Child Care Assistance Program

Policies.

3. Parent(s)/Guardian(s) failure to notify CCAP regarding any type of changes in writing (i.e., income,

address, new provider, phone number, employment, late or unpaid fees) that relate to CCAP, within five

(5) working days.

4. Parent(s)/Guardian(s)/Providers knowingly giving any inaccurate or false information (verbally or

written) to CCAP.

5. Parent(s)/Guardian(s)/Providers falsification of signatures, hours and rates of service on any CCAP forms.

6. Providers found to have used alcohol or drugs, or prescription drugs during the hours of child care services.

7. Providers found to have been convicted of a felony, DWI, or any illegal involvement that would affect the

ability to care for children as regulated by state child care certification/licensing laws.

REPORTING 1. PARENTS and PROVIDERS are obligated to immediately report any type of Neglect, Physical Abuse, Sexual

Abuse, Mental Abuse, and Emotional Abuse to proper authorities.

2. PARENTS will give PROVIDERS a TWO-WEEK/14 DAY notice when the parent has become ineligible for

assistance or no longer wishes to utilize the child care center.

Parent(s)/Guardian(s) violating policy will be notified in writing and/or verbally of this action.

Parent(s)/Guardian(s) will be given written notification if it is deemed necessary to terminate child care

services.

CCAP may proceed with an investigation, if one is deemed necessary. You will be notified by phone by the

tenth (10th) work day, regarding the investigation. A decision for continuance of child care services will be

discussed at that time.

My signature acknowledges that I have read and fully understand the CCAP Discharge Policy.

_______________________________________ ______________________

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Parent(s)/Guardian(s) Signature Date

RELEASE OF INFORMATION

Complete all sections of this form before you sign at the bottom.

Your information cannot be passed on to any other agency/individual without your written/verbal permission.

RELEASE OF INFORMATION: Permission is given to the Tribe to contact my childcare provider, employer, school, or

training program before and after the application has been approved. I hereby give my permission to CCAP to contact my

designated child care provider to give notice of eligibility and to schedule a site visit and also to contact the Wisconsin

Department of Human Services (or the state’s DHS in which you reside) for the purpose of verification of dual participation.

Initial ______

PHOTOGRAPHS: Children from time to time will be photographed, videotaped or audio taped in the context of classroom,

playground or off-site activities for child care only. This usage could include but not limited to pictures on the Nation’s website, tribal newspaper, federal reporting, brochures and files.

Initial______

Ho-Chunk Nation Department of Social Services

Division of Community Supportive Services

P.O. Box 40 808 Red Iron Road


Child’s full name: Child’s full name: 1. _____________________ __________ 2. _____________________ __________ 3. _____________________ __________ 4. _____________________ __________ 5. _____________________ __________ 6. _____________________ __________ 7. _____________________ __________ 8. _____________________ __________ 9. _____________________ __________ 10.________________________________

To release information to: Either verbal and/or written; regarding your application for assistance/current

assistance (Check all that apply below)

Client information HCN Enrollment Intake Assessment

HCN Social Services Child Care Center Court Orders

Client History School Attendance Place of Employment

Other (Specify):

A copy of this release serves the same function as the original signed release. This authorization can be revoked at any time prior to

this date or action by providing written notice to Ho-Chunk Nation Division of Community Supportive Services. I understand that

any information released prior to revocation of this authorization, cannot be retrieved.

_______________________________________________________ __________________________

Signature of Parent/Legal Guardian/Person Legally Authorized to Date

Consent for Individual

2 3 4 5 6 7 8 9 10 1 2 3 4 5+ 1 child 2 children 3 children 4 children 5 children

Under

$1,335.00

Under

$1,680.00

Under

$2,025.00

Under

$2,370.00

Under

$2,715.00

Under

$3,061.00

Under

$3,408.00

Under

$3,754.00

Under

$4,101.00 $0.00 $0.00 $0.00 $0.00 $0.00 n/a n/a n/a n/a n/a

$1,335.00 $1,680.00 $2,025.00 $2,370.00 $2,715.00 $3,061.00 $3,408.00 $3,754.00 $4,101.00 $6.00 $10.00 $16.00 $21.00 $27.00 1.80% 2.38% 3.16% 3.54% 3.98%

$1,422.00 $1,790.00 $2,159.00 $2,527.00 $2,896.00 $3,264.00 $3,633.00 $4,001.00 $4,370.00 $6.00 $13.00 $19.00 $25.00 $31.00 1.69% 2.91% 3.52% 3.96% 4.28%

$1,486.00 $1,872.00 $2,257.00 $2,642.00 $3,027.00 $3,413.00 $3,798.00 $4,183.00 $4,568.00 $9.00 $15.00 $21.00 $28.00 $34.00 2.42% 3.21% 3.72% 4.24% 4.49%

$1,551.00 $1,953.00 $2,355.00 $2,757.00 $3,159.00 $3,561.00 $3,963.00 $4,365.00 $4,767.00 $13.00 $19.00 $25.00 $31.00 $40.00 3.35% 3.89% 4.25% 4.50% 5.06%

$1,616.00 $2,034.00 $2,453.00 $2,872.00 $3,291.00 $3,709.00 $4,128.00 $4,547.00 $4,966.00 $15.00 $24.00 $31.00 $39.00 $46.00 3.71% 4.72% 5.06% 5.43% 5.59%

$1,680.00 $2,116.00 $2,551.00 $2,987.00 $3,422.00 $3,858.00 $4,293.00 $4,729.00 $5,164.00 $19.00 $28.00 $37.00 $46.00 $53.00 4.52% 5.29% 5.80% 6.16% 6.20%

$1,745.00 $2,197.00 $2,649.00 $3,102.00 $3,554.00 $4,006.00 $4,458.00 $4,911.00 $5,363.00 $21.00 $31.00 $40.00 $51.00 $59.00 4.81% 5.64% 6.04% 6.58% 6.64%

$1,810.00 $2,279.00 $2,748.00 $3,217.00 $3,686.00 $4,155.00 $4,624.00 $5,093.00 $5,562.00 $25.00 $34.00 $45.00 $53.00 $63.00 5.52% 5.97% 6.55% 6.59% 6.84%

$1,874.00 $2,360.00 $2,846.00 $3,331.00 $3,817.00 $4,303.00 $4,789.00 $5,274.00 $5,760.00 $28.00 $38.00 $46.00 $57.00 $66.00 5.98% 6.44% 6.47% 6.84% 6.92%

$1,939.00 $2,441.00 $2,944.00 $3,446.00 $3,949.00 $4,451.00 $4,954.00 $5,456.00 $5,959.00 $31.00 $40.00 $51.00 $60.00 $69.00 6.40% 6.55% 6.93% 6.96% 6.99%

$2,003.00 $2,523.00 $3,042.00 $3,561.00 $4,080.00 $4,600.00 $5,119.00 $5,638.00 $6,157.00 $34.00 $45.00 $53.00 $62.00 $73.00 6.79% 7.13% 6.97% 6.96% 7.16%

$2,068.00 $2,604.00 $3,140.00 $3,676.00 $4,212.00 $4,748.00 $5,284.00 $5,820.00 $6,356.00 $38.00 $48.00 $57.00 $67.00 $78.00 7.35% 7.37% 7.26% 7.29% 7.41%

$2,133.00 $2,685.00 $3,238.00 $3,791.00 $4,344.00 $4,896.00 $5,449.00 $6,002.00 $6,555.00 $40.00 $52.00 $63.00 $74.00 $85.00 7.50% 7.75% 7.78% 7.81% 7.83%

$2,197.00 $2,767.00 $3,336.00 $3,906.00 $4,475.00 $5,045.00 $5,614.00 $6,184.00 $6,753.00 $44.00 $56.00 $68.00 $81.00 $93.00 8.01% 8.10% 8.15% 8.29% 8.31%

$2,262.00 $2,848.00 $3,434.00 $4,021.00 $4,607.00 $5,193.00 $5,779.00 $6,366.00 $6,952.00 $46.00 $59.00 $73.00 $85.00 $99.00 8.13% 8.29% 8.50% 8.46% 8.60%

$2,327.00 $2,930.00 $3,533.00 $4,136.00 $4,739.00 $5,342.00 $5,945.00 $6,548.00 $7,151.00 $50.00 $62.00 $74.00 $88.00 $101.00 8.59% 8.46% 8.38% 8.51% 8.53%

$2,391.00 $3,011.00 $3,631.00 $4,250.00 $4,870.00 $5,490.00 $6,110.00 $6,729.00 $7,349.00 $53.00 $65.00 $79.00 $91.00 $105.00 8.87% 8.64% 8.70% 8.56% 8.62%

$2,456.00 $3,092.00 $3,729.00 $4,365.00 $5,002.00 $5,638.00 $6,275.00 $6,911.00 $7,548.00 $56.00 $68.00 $81.00 $94.00 $107.00 9.12% 8.80% 8.69% 8.61% 8.56%

$2,520.00 $3,174.00 $3,827.00 $4,480.00 $5,133.00 $5,787.00 $6,440.00 $7,093.00 $7,746.00 $59.00 $73.00 $85.00 $98.00 $111.00 9.37% 9.20% 8.88% 8.75% 8.65%

$2,585.00 $3,255.00 $3,925.00 $4,595.00 $5,265.00 $5,935.00 $6,605.00 $7,275.00 $7,945.00 $60.00 $74.00 $87.00 $100.00 $113.00 9.28% 9.09% 8.87% 8.71% 8.58%

$2,650.00 $3,336.00 $4,023.00 $4,710.00 $5,397.00 $6,083.00 $6,770.00 $7,457.00 $8,144.00 $62.00 $79.00 $91.00 $105.00 $117.00 9.36% 9.47% 9.05% 8.92% 8.67%

$2,715.00 $3,417.00 $4,121.00 $4,825.00 $5,529.00 $6,231.00 $6,935.00 $7,639.00 $8,369.00 $64.00 $80.00 $94.00 $108.00 $119.00 9.43% 9.36% 9.12% 8.95% 8.61%

$2,780.00 $3,498.00 $4,219.00 $4,940.00 $5,661.00 $6,379.00 $7,100.00 $7,821.00 Not Eligible $66.00 $83.00 $98.00 $111.00 $122.00 9.50% 9.49% 9.29% 8.99% 8.62%

$2,845.00 $3,579.00 $4,317.00 $5,055.00 $5,793.00 $6,527.00 $7,265.00 $8,003.00 Not Eligible $68.00 $86.00 $101.00 $113.00 $126.00 9.56% 9.61% 9.36% 8.94% 8.70%

$2,910.00 $3,660.00 $4,415.00 $5,170.00 $5,925.00 $6,675.00 $7,430.00 $8,194.00 Not Eligible $70.00 $87.00 $104.00 $116.00 $128.00 9.62% 9.51% 9.42% 8.97% 8.64%

$2,975.00 $3,741.00 $4,513.00 $5,285.00 $6,057.00 $6,823.00 $7,595.00 Not Eligible Not Eligible $72.00 $90.00 $107.00 $119.00 $133.00 9.68% 9.62% 9.48% 9.01% 8.78%




$3,235.00 $4,065.00 $4,905.00 $5,745.00 $6,585.00 $7,415.00 Not Eligible Not Eligible Not Eligible $80.00 $101.00 $119.00 $131.00 $144.00 9.89% 9.94% 9.70% 9.12% 8.75%




$3,495.00 $4,389.00 $5,297.00 $6,205.00 $7,113.00 Not Eligible Not Eligible Not Eligible Not Eligible $88.00 $113.00 $131.00 $143.00 $156.00 10.07% 10.30% 9.89% 9.22% 8.77%





$3,820.00 $4,794.00 $5,812.00 Not Eligible Not Eligible Not Eligible Not Eligible Not Eligible Not Eligible $98.00 $128.00 $146.00 $158.00 $171.00 10.26% 10.68% 10.05% n/a n/a

$3,885.00 $4,882.00 Not EligibleNot Eligible Not Eligible Not Eligible Not Eligible Not Eligible Not Eligible $100.00 $131.00 $149.00 $161.00 $174.00 10.30% 10.73% n/a n/a n/a

$3,952.00 Not EligibleNot EligibleNot Eligible Not Eligible Not Eligible Not Eligible Not Eligible Not Eligible $102.00 $134.00 $152.00 $164.00 $177.00 10.32% n/a n/a n/a n/a

Gross Monthly Family Income

& Number in Household

# of Children in Daycare

& Weekly Co-Pay

Percentage of monthly income

pd by single parent

HO-CHUNK NATION

Child Care Co-Payment Schedule Effective 10-1-16

COMPLAINT REPORTING FORM

The purpose of this form is to assist you in filing a complaint with the Ho-Chunk Nation Social Services Department.

STATE YOUR NAME AND ADDRESS: Date Reporting:

Name:

Address:

Home Phone #: Work Phone #:

DIVISIONS

Please check which division you have a complaint with.

Youth Services (YS) Child and Family Services (CFS)

Community Support Service (CSS) Tribal Aging Unit (TAU)

Domestic Violence (DV) Child Support Enforcement (CSE)

Date of Complaint:

Location of Complaint:

Time:

Person(s) involved:

DESCRIPTION OF COMPLAINT:

(Please describe your complain in detail below,

if you need more space to write, please use another sheet of paper.)

Once the report is received by the department, we will investigate the complaint and respond within 10 (ten) business days.

Documents Attached

Please Mail the copies to:

Attn: Executive Director of Social Services

HCN Dept. of Social Services

PO Box 40

Black River Falls WI 54615